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5 Diagnoses That Call for a Second Opinion

or if there's anyquestion about whether it's truly cancer -- seek a second opinion from apathologist who has expertise in diagnosing this type of malignancy. After all,the diagnosis will determine which treatment is best.B B

"There are certain kinds of tumors that provide a lot more difficultiesin diagnosis," says John E. Tomaszewski, MD, FASCP, vice chairman ofAnatomic Pathology-Hospital Services at the University of Pennsylvania Schoolof Medicine. For example, sarcomas -- an uncommon cancer of soft tissues, suchas muscle or fat -- can be complex to classify. "A general pathologist maynot see a lot of soft-tissue tumors," he says.

Major medical centers that see larger numbers of rare or unusual tumors areoften a better choice for a second opinion than a smaller hospital, accordingto John S.J. Brooks, MD, FASCP, president of the American Society for ClinicalPathology. "These folks that have very rare tumors, [a hospital] near themmay only see very few," he says.B

Getting that second opinion can help catch errors.

"Anytime there's uncertainty, it's always fine [to get a secondopinion]," Tomaszewski says. "Pathology ... is like every other area ofmedicine. There are things that are very clear and things that are on theborderline."

2. ADHD in Children Under Age 6

With no specific lab test for attention deficit hyperactivity disorder(ADHD), the problem can be tough to diagnose accurately. A doctor's judgmentcomes into play; he or she may diagnose ADHD if a child shows hyperactivity,inattention, and impulsivity in at least two settings, such as home andschool.

When a child under age 6 is diagnosed with ADHD, parents may want a secondopinion from a specialist, such as a child psychiatrist, says Sara Rizvi, MD,assistant professor of pediatrics at the Baylor College of Medicine. That'sbecause ADHD symptoms, such as too much talking or fidgeting, can overlap withbehavior that's typical among young children.

"Many of the symptoms are common among preschool children," Rizvisays. "Part of it is because of their developmental stage and level ofactivity and normal short attention spans." A second opinion can helpdetermine if symptoms are serious enough to be classified as ADHD.

It's also crucial to rule out other mental disorders that can be confusedwith ADHD, according to Rizvi. These include developmental problems, learningdisabilities, anxiety, and depression. Sometimes, children who witness domesticviolence may behave in ways that suggest ADHD, Rizvi says. "They tend to bemore inattentive to their class work, more impulsive. A lot of those childrenare actually misdiagnosed with ADHD when in fact they may be manifestingsymptoms of posttraumatic stress disorder."

3. Parkinson's Disease

"Parkinson's is one of the most difficult diseases to diagnose. There'sno blood test, X-ray, or instrument that would give you an answer," saysExecutive Director Robin Elliott of the Parkinson's Disease Foundation.

Diagnosis of this neurological disorder -- marked by tremors, slow movement,muscle stiffness, and loss of balance -- is based "not on a very specifictest, but a cluster of features," says David C. Dale, MD, president of theAmerican College of Physicians. Parkinson's can be especially difficult todiagnose in the early stages.

The rate of misdiagnosis among people with Parkinson's may be as high as25%-30%, Elliott says. In the elderly, the trembling and movement problems ofParkinson's may be dismissed as normal aging. Conversely, patients may bewrongly diagnosed with Parkinson's when their symptoms actually stem from sideeffects of drugs they're taking, such as certain psychiatricmedicines.B

Even well-trained internists and general neurologists can have troublediagnosing Parkinson's disease, especially if they've had little experiencewith the disorder, according to lliott. As a result, the Parkinson's DiseaseFoundation suggests that people diagnosed with Parkinson's consider getting asecond opinion from a neurologist who specializes in movement disorders and hasextensive experience with Parkinson's.B

4. Heart Procedures

What prompts heart patients to seek second opinions?

"Probably the most common situation is that someone has been advised tohave open heart surgery or a coronary intervention or a catheterization, andthey're wondering if they really need that," says David L. Rutlen, MD, vicechairman of ambulatory programs at the Froedtert and Medical College ofWisconsin, which has a cardiac second opinion program. In other words, patientswant extra advice before consenting to invasive heart procedures that carryserious risks, such as blood clots, stroke, infection, and even death.

A second opinion makes sense "if the patient has any concern that thisis a treatment plan that may not be best for them," Rutlen says. Forexample, patients may wonder whether they truly need bypass surgery or if,instead, they can undergo balloon angioplasty to open up blocked arteries.

Some patients also seek out a second opinion in hopes of finding an expertwith greater experience in performing the procedure they require, Rutlensays.

Also, if a patient remains undecided after the first cardiologist has listedmultiple treatment options, "a second opinion from another cardiologistwould be an excellent consideration," Rutlen says.

5. Depression and Bipolar Disorder

Primary care physicians often diagnose cases of depression, but sometimes asecond opinion from a psychiatrist is in order.

If patients diagnosed with depression don't improve after trying at least acouple of antidepressants, or if they develop adverse effects, such as mania,they may actually have bipolar disorder, says Florence Kim, MD. She is apsychiatrist and director of the Menninger Clinic's Comprehensive PsychiatricService, where patients can obtain psychiatric second opinions.B

Why do the two disorders become confused? Some patients with bipolardisorder -- also called "manic-depressive illness" -- don't have amanic episode early on, so it's easy for doctors to mistake the two diseases.In fact, patients with a less severe form of bipolar disorder may never developintense mania, but instead have milder manic episodes that alternate withdepression.

In fact, as many as 69% of bipolar patients may receive a wrong initialdiagnosis, according to Mark Graber, MD, chief of the medical service at the VAMedical Center in Northport, N.Y. Graber has done research to find ways toreduce diagnostic errors.

A proper diagnosis matters. Doctors treat depression with drugs such asantidepressants, while bipolar disorder typically requires mood stabilizers,such as lithium, either alone or in combination with antidepressants. Whenbipolar patients take antidepressants alone, they're at risk of switching intomania or developing rapid cycling between the highs and lows.

"I'm actually all for psychiatric intervention in the primary caresetting," Kim says. "I think it's perfectly reasonable to try anantidepressant, but people just have to be educated. They have to know that ifthey're having adverse effects to the medication that they should see apsychiatrist. Or if they do start to feel manic effects from theantidepressants, they should see a psychiatrist."B B B

But some patients balk, Kim says. "You almost have to hit them over thehead to go to a psychiatrist. They would rather tough it out with their primarycare physician because that way, they don't have to tell people they havepsychiatric problems."